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<h1 style="text-align:left; font-size: 2em" >Reclamos M&oacute;viles - Test</h1>
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<form action="services/xml/reclamos.php?XDEBUG_SESSION_START=debug1"
 enctype="multipart/form-data"
 method="POST" target="frm1" style="left-margin:auto; right-margin:auto; margin: 10px 10px">

<input type="hidden" name="user" value="l34ndr0m1lm4nd4@@" />

<div style="width:250px; float: left;">
<div style="width:250px; text-align:left" >Status</div><div style="width:250px; text-align:left" ><input  name="status" type="text" value="1" /></div><br/>
<div style="width:250px; text-align:left" >Nombre</div><div style="width:250px; text-align:left" ><input  name="nombre" type="text" value="nombre<?php echo $_GET['tag'] ?>" /></div><br/>
<div style="width:250px; text-align:left" >Apellido</div><div style="width:250px; text-align:left" ><input  name="apellido" type="text" value="apellido<?php echo $_GET['tag'] ?>" /></div><br/>
</div>


<div style="width:250px; float: left;">
<div style="width:250px; text-align:left" >Tipo Doc.</div><div style="width:250px; text-align:left" ><input  name="doc_tipo" type="text" value="1" /></div><br/>
<div style="width:250px; text-align:left" >Document</div><div style="width:250px; text-align:left" ><input  name="doc" type="text" value="12123123" /></div><br/>
<div style="width:250px; text-align:left" >Telefono</div><div style="width:250px; text-align:left" ><input  name="telefono" type="text" value="4555-5567" /></div><br/>
</div>


<div style="width:250px; float: left;">
<div style="width:250px; text-align:left" >Tipo Reclamo</div><div style="width:250px; text-align:left" ><input  name="tipo" type="text" value="1" /></div><br/>
<div style="width:250px; text-align:left" >Calle</div><div style="width:250px; text-align:left" ><input  name="calle" type="text" value="calle<?php echo $_GET['tag'] ?>" /></div><br/>
<div style="width:250px; text-align:left" >Calle Altura</div><div style="width:250px; text-align:left" ><input  name="calle_alt" type="text" value="1500" /></div><br/>
</div>


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<div style="width:250px; text-align:left" >GPS Lat</div><div style="width:250px; text-align:left" ><input  name="gps_lat" type="text" value="gps_lat<?php echo $_GET['tag'] ?>" /></div><br/>
<div style="width:250px; text-align:left" >GPS Long</div><div style="width:250px; text-align:left" ><input  name="gps_long" type="text" value="gps_long<?php echo $_GET['tag'] ?>" /></div><br/>
</div>






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<div style="width:250px; text-align:left" >Imagen&nbsp;<input name="picture" type="file" value="gps_long<?php echo $_GET['tag'] ?>" /></div>
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<input style="width:100px; float: left;" type="submit" name="submit" /><br/>
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</form>

<iframe name="frm1" style="border: 1px solid #000; width:100%; height: 370px" src=""></iframe>


</body>
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